Provider Demographics
NPI:1689981888
Name:SAN JORGE CHILDRENS MEDICAL SPEIALTIES
Entity Type:Organization
Organization Name:SAN JORGE CHILDRENS MEDICAL SPEIALTIES
Other - Org Name:SJC MEDICAL SPECIALTIES
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLAVELL
Authorized Official - Suffix:
Authorized Official - Credentials:5762
Authorized Official - Phone:787-728-1575
Mailing Address - Street 1:252 CALLE SAN JORGE
Mailing Address - Street 2:SAN JORGE MEDICAL BLDG 504
Mailing Address - City:SANTURCE
Mailing Address - State:PR
Mailing Address - Zip Code:00912-3239
Mailing Address - Country:US
Mailing Address - Phone:787-728-1575
Mailing Address - Fax:787-726-0402
Practice Address - Street 1:252 CALLE SAN JORGE
Practice Address - Street 2:SAN JORGE MEDICAL BLDG 504
Practice Address - City:SANTURCE
Practice Address - State:PR
Practice Address - Zip Code:00912-3239
Practice Address - Country:US
Practice Address - Phone:787-728-1575
Practice Address - Fax:787-726-0402
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SJC MEDICAL SPECIALTIES AMB. SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5762174400000X
PR9083174400000X
PR9183174400000X
PR11147174400000X
PR12902174400000X
PR13693174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR12501OtherTRIPLE S
PR20062OtherTRIPLE S